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,AN JOAQUIN I,OUN'I'Y ENVIRONMENTAL nEALTH LEPARYMEN'I <br /> SERVICE REQUEST <br /> Type of Business or Property FACRM 13#FSERVICE REQUEST# <br /> SRGDC.J ( 5 -�-- <br /> OWNER/OPERATOR -TDNy �IP%??tE \\ II CNECK It BILLING ADDRESS® <br /> FACIHT NAME CV-h PrPP C -Y INOLM S <br /> SITE ADDRESS 2.-+ o t. i.}t GI4t.v Ay �- >F'AR,tA41PJG T'O r.J <br /> Street Number D" Street N 51--,3 G <br /> HOME or MAILING ADDRESS (N Different from Site Address) 7`+ 19 S 1-A tV LEY Xb . <br /> Short Numbw me _ <br /> CITY 5 ^J STATE GA ZIP C1 5-2-1 <br /> PHONE tft �' APN# I-min USE APPucATN7N# <br /> 4-41 - 5" ---/� /?9 -t3- PJfCHs) <br /> PHONE#2 E T. BGS DISTRICT LOCATKIN CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOuESTOR AABY 9-NCCO CNEcK N BILLING ADDRESS <br /> BUSINESS NAME /rJPHONE# E`�" <br /> LIJ� OAK. G£O�Ne/IRen1WIgIV7AL 20`1 3�°�- d3�s <br /> HOME or MAILNiG ADDRESST#-4 W. 0*1L (-X67 ) 36e1- Off } <br /> CITY ( ,OD i, STATE C A ZIP 4S Zq0 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL flHALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE d F RAL l S. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER)q OTHER AUTHoRizED AGENT❑ <br /> 1f fPPL/CdNr it nap the Bru✓NG PARTY.proof of andorizadon to sign is required Titfe <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sante time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REINIESTED:_jZEvItZVj $URAL£ + SJ13/5 VlL�AGE CpnlfAwtlArAT10 <br /> COMMENTS: ?, NO /�'f`t3 <br /> t <br /> MAY 14 2013 <br /> 1 <br /> ACCEPTED BY: I l . ��D,� EMPLOYEE#: 2670 DATE: S7/it <br /> SI3 <br /> ASGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SENVICE CODE: 3 cJ.— PIE: <br /> ?(fl D <br /> Fee Amount: n• Amount Paid P,.2 6-0. b!) Payment Date :�/e� 3 <br /> Payment Typo Invoice# Check# 369q75- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />